Printed from www.taxmann.com FORM NO. 12BA [See rule 26A(2)(b)] Statement showing particulars of perquisites, other fringe benefits or amenities and profits in lieu of salary with value thereof 1. Name and address of employer : 2. TAN : 3. TDS Assessment Range of the employer : 4. Name, designation and PAN of employee : 5. Is the employee a director or a person with substantial interest in the company (where the employer is a company) : 6. Income under the head "Salaries" of the employee (other than from perquisites) : 7. Financial year : 8. Valuation of Perquisites : S. No. Nature of perquisites (see rule 3) Value of perquisite as per rules (Rs.) Amount, if any, recovered from the employee (Rs.) Amount of perquisite chargeable to tax Col. (3) - Col. (4) (Rs.) (1) (2) (3) (4) (5) 1. Accommodation 2. Cars/Other automotive 3. Sweeper, gardener, watchman or personal attendant 4. Gas, electricity, water 5. Interest free or concessional loans 6. Holiday expenses 7. Free or concessional travel 8. Free meals 9. Free education 10. Gifts, vouchers, etc. 11. Credit card expenses 12. Club expenses 13. Use of movable assets by employees 14. Transfer of assets to employees 15. Value of any other benefit/amenity/service/privilege 16. Stock options (non-qualified options) 17. Other benefits or amenities 18. Total value of perquisites 19. Total value of profits in lieu of salary as per section 17(3) (9) Details of tax, (a) Tax deducted from salary of the employee under ti 192(1) Printed from www.taxmann.com section 192(1) (b) Tax paid by employer on behalf of the employee under section 192(1A) (c) Total tax paid (d) Date of payment into Government treasury DECLARATION BY EMPLOYER I,________________________________________ , s/o___________________________________working as______________________________(designation) do hereby declare on behalf of__________________________________(name of the employer) that the information given above is based on the books of account, documents and other relevant records or information available with us and the details of value of each such perquisite are in accordance with section 17 and rules framed thereunder and that such information is true and correct. Signature of the person responsible for deduction of tax Place Full Name Date Designation